Intraoperative Blood Loss Estimation in Hepato-pancreato-biliary Surgery-Relevant, Not Reported, Not Standardized: Results From a Systematic Review and a Worldwide Snapshot Survey

Objective: To provide an overview of the current practice of intraoperative blood loss (BL) estimation in hepato-pancreato-biliary (HPB) surgery. Background: Intraoperative BL is a major quality marker in HPB surgery and a predictor of perioperative outcomes. However, the method for BL estimation is not standardized. Methods: A systematic review was performed of original studies published between 2006 and 2021 reporting the intraoperative BL of patients undergoing pancreatic or hepatic resections. A web-based snapshot survey was distributed globally to all members of the International Hepato-Pancreato-Biliary Association (IHPBA). Results: A total of 806 studies were included; 480 (60%) had BL as their primary outcome, and 105 (13%) had BL as their secondary outcome. However, 669 (83%) did not specify how BL estimation was performed, and 9 different methods were found among the remaining 136 (17%) studies.The survey was completed by 252 surgeons. Most of the responders (94%) declared that they systematically performed BL estimation and considered BL predictive of postoperative complications after pancreatic (73%) and liver (74%) resection. All methods previously identified in the literature were used by responders with different frequencies. A calculation based on suction fluid amounts, operative gauze weight, and irrigation was the most used method in the literature (7%) and among responders (51%). Most responders (83%) felt that BL estimation in HPB surgery needs improved standardization. Conclusions: Standardization of intraoperative BL estimation is urgently needed in HPB surgery to ensure the consistency of reporting and reproducibility.